Sacropelvic fixation techniques - Current update

Sacropelvic is a complex junctional area owing to the complex regional anatomy and higher biomechanical stress. However extension of construct is indicated in cases with complex deformities, high grade spondylolisthesis, and complex fractures. The challenges remain which includes pseudoarthrosis and fixation failures. The fixation techniques have constantly evolved over time with better results with iliac screws and S2-alar-iliac screws. This article gives background on evolution, biomechanics, and recent update of use of robotics for sacropelvic fixation.     

Implementation and evaluation of a novel subspecialty society fellows robotic surgical course: the SGO minimally invasive academy surgical curriculum

ObjectiveTo evaluate the utility of a society-based robotic surgery training program for fellows in gynecologic oncology.MethodsAll participants underwent a 2-day robotic surgery training course between 2015–2017. The course included interactive didactic sessions with video, dry labs, and robotic cadaver labs. The labs encompassed a wide range of subject matter including troubleshooting, instrument variation, radical hysterectomies, and lymph node dissections. Participants completed a pre- and post-course survey using a 5-point Likert scale ranging from “not confident” to “extremely confident” on various measures. Statistical analysis was performed using SPSS Statistics v. 24.ResultsThe response rate was high with 86% of the 70 participants completing the survey. Sixteen (26.7%) of these individuals were attending physicians and 44 (73.3%) were fellows. In general, there was a significant increase in confidence in more complex procedures and concepts such as radical hysterectomy (p=0.01), lymph node dissection (p=0.01), troubleshooting (p=0.001), and managing complications (p=0.004). Faculty comfort and practice patterns were cited as the primary reason (58.9%) for limitations during robotic procedures followed secondarily by surgical resources (34.0%).ConclusionIn both gynecologic oncology fellows and attendings, this educational theory-based curriculum significantly improved confidence in the majority of procedures and concepts taught, emphasizing the value of hands-on skill labs.     

Changing trends in the minimally invasive surgery for corrosive esophagogastric stricture

Esophagogastric stricture is the troublesome long-term complication of corrosive ingestion with a significant adverse impact on the quality of life. Surgery remains the mainstay of therapy in patients where endoscopic treatment is not feasible or fails to dilate the stricture. Conventional surgical management of esophageal stricture is open esophageal bypass using gastric or colon conduit. Colon is the commonly used esophageal substitute, particularly in those with high pharyngoesophageal strictures and in patients with accompanying gastric strictures. Traditionally colon bypass is performed using an open technique that requires a long midline incision from the xiphisternum to the suprapubic area, with adverse cosmetic outcomes and long-term complications like an incisional hernia. As most of the affected patients are in the second or third decade of life minimally invasive approach is an attractive proposition. However, minimally invasive surgery for corrosive esophagogastric stricture is slow to evolve due to the complex nature of the surgical procedure. With advancements in laparoscopic skills and instrumentation, the feasibility and safety of minimally invasive surgery in corrosive esophagogastric stricture have been documented. Initial series have mainly used a laparoscopic-assisted approach, whereas more recent studies have shown the safety of a total laparoscopic approach. The changing trend from laparoscopic assisted procedure to a totally minimally invasive technique for corrosive esophagogastric stricture should be carefully disseminated to preclude adverse long-term outcomes. Also, well-designed trials with long-term follow-ups are required to document the superiority of minimally invasive surgery for corrosive esophagogastric stricture. The present review focuses on the challenges and changing trends in the minimally invasive treatment of corrosive esophagogastric stricture.     

肝下下腔静脉阻断技术在机器人辅助腹腔镜肝切除术中的应用效果

目的探讨肝下下腔静脉阻断技术在机器人肝切除术中的可行性和有效性。方法回顾性分析2015年2月至2017年12月华中科技大学同济医学院附属同济医院肝脏外科中心采用机器人行肝切除术治疗的24例患者资料,根据术中控制低中心静脉压的方式不同分为肝下下腔静脉阻断组(8例)和低中心静脉压组(16例)。肝下下腔静脉阻断组男性6例,女性2例,年龄49岁(范围:20~56岁);低中心静脉压组男性15例,女性1例,年龄53岁(范围:38~69岁)。通过t检验、非参数检验、χ2检验或Fisher确切概率法比较两组患者的术中出血量、肝门阻断时间、输血量、术中血流动力学变化及术后并发症、肝肾功能变化等。结果肝下下腔静脉阻断组的术中出血量[M(QR)]为200(220)ml(范围:100~400 ml),低于低中心静脉压组的750(800)ml(范围:100~2000 ml)(Z=-2.169,P=0.030)。肝下下腔静脉阻断组第一肝门阻断时间为24(18)min,肝下下腔静脉阻断时间为29(20)min,低中心静脉压组第一肝门阻断时间为23(23)min,两组第一肝门阻断时间的差异无统计学意义(Z=-0.323,P=0.747)。肝下下腔静脉阻断组无术中输血病例,低中心静脉压组术中输血5例,输血量1.5(1.5)U,两组输血量的差异有统计学意义(Z=-3.353,P=0.001)。术中阻断肝下下腔静脉后,患者平均动脉压由(88.6±4.9)mmHg(1 mmHg=0.133 kPa)降至(67.4±3.8)mmHg,低于低中心静脉压组的(72.4±3.3)mmHg(t=2.315,P=0.003)。两组患者的术后并发症及肝肾功能变化的差异均无统计学意义(P值均>0.05)。结论在机器人辅助腹腔镜肝切除术中,可通过肝下下腔静脉阻断技术控制患者的中心静脉压,操作简单,对患者的肝肾功能无明显影响。     

机器人辅助经皮螺钉内固定治疗骨盆和髋臼骨折

目的：评价一种外科手术机器人辅助经皮螺钉内固定治疗骨盆和髋臼骨折手术的安全性与有效性。方法： 选择2016年1至4月北京积水潭医院创伤骨科收治的12例骨盆和髋臼骨折患者为研究对象,将试验对象随机分为试验组和对照组,试验组7例采用机器人辅助下医生完成手术,对照组5例采用透视引导下医生徒手完成手术,通过对两组病例的手术总时间、术中透视时间、导针调整次数、螺钉置入位置优良率和不良事件发生率进行统计分析,评价机器人辅助骨盆和髋臼骨折进行经皮螺钉内固定治疗的有效性和安全性。结果： 试验组7例患者共置入11枚螺钉,对照组5例患者共置入7枚螺钉。术后CT透视检查确认所有螺钉位置均满意,但两组螺钉的分布差异有统计学意义（P=0.016）,试验组优率高于对照组;试验组平均螺钉置入所需透视时间为(7.36±2.63) s,短于对照组的(41.80±13.99) s,差异有统计学意义（P<0.001）;试验组术中平均螺钉调整次数为(0.36±0.48)次,少于对照组的(9.00±3.06)次,两组差异具有统计学意义（P=0.003）;试验组平均手术时间为(43.86±49.06) min,对照组为(29.00±12.14) min,两组差异无统计学意义（P=0.528）。进行CT透视确认所有螺钉位置满意,未见穿出骨皮质及进入关节腔者,未见伤口感染等其他螺钉置入的相关并发症发生。结论： 外科手术机器人适用于辅助进行骨盆和髋臼骨折经皮螺钉内固定治疗,并具有置入准确性高、透视辐射小、安全有效等优点。     

机器人辅助腹腔镜前列腺癌根治术经腹膜途径和腹膜外途径术后肺不张观察

应用肺部超声技术比较经腹膜途径机器人辅助腹腔镜前列腺癌根治术（transperitoneal robot-assisted laparoscopic radical prostatectomy, T-RLRP）和腹膜外途径机器人辅助腹腔镜前列腺癌根治术（extraperitoneal robot-assisted laparoscopic radical prostatectomy, E-RLRP）术后肺不张情况。 方法 采用随机数字表法将40例患者分为T-RLRP组和E-RLRP组,每组20例。两组患者分别于麻醉前（T0）,建立气腹和Trenderlenburg体位后60 min（T1）、120 min（T2）和气管拔管后（T3）,抽取桡动脉血,观察PaO2/FiO2和PaCO2;记录气腹和Trenderlenburg体位后120 min内的平均气道压;术毕拔管前,肺部超声下观察患者肺不张程度。 结果 术中T-RLRP组的平均气道压高于E-RLRP组（P＜0.05）。T-RLRP组PaO2/FiO2水平T1和T2时点明显低于T0水平（P＜0.05,P＜0.01）,T2时点低于T1时点水平（P＜0.05）。E-RLRP组在T2时PaO2/FiO2水平低于T0（P＜0.05）,T1、T2和T3时点PaO2/FiO2水平均明显高于T-RLRP组（P＜0.01,P＜0.05,P＜0.05）。两组T1和T2时点PaCO2明显高于T0（P＜0.01）,T-RLRP组T1和T2时点PaCO2均高于E-RLRP组（P＜0.05）。术毕肺部超声显示肺不张1级、2级和3级,T-RLRP组比例均明显高于E-RLRP组（P＜0.01）。 结论 相比T-RLRP组,E-RLRP对患者术中和术后氧合影响更小,术后肺不张发生程度更轻。     

复发肾上腺肿瘤患者行经腹腹腔镜手术的技巧

目的 探讨经腹腹腔镜手术治疗复发肾上腺肿瘤的手术疗效和技巧. 方法 我院于2013年10月至2017年1月采用腹腔镜技术治疗复发肾上腺肿瘤患者12例,其中男5例,女7例.年龄25~68岁,平均51岁.术前CT提示左侧7例,右侧5例.12例中原发性醛固酮增多症8例、嗜铬细胞瘤2例、肾上腺皮质癌2例.除1例肾上腺皮质癌患者既往接受左侧开放11肋间切口术式外,其余11例患者既往均为后腹腔镜手术入路.本次手术均在全麻下进行,12例患者均采用健侧卧位经腹腔途径结肠旁沟入路,8例采用普通腹腔镜肾上腺切除术,4例采用机器人辅助腹腔镜肾上腺切除术. 结果 12例手术均获成功,无1例中转开放.肾上腺肿瘤大小1.0~8.0 cm,平均3.5 cm.手术时间25~93 min,平均48 min.术中出血量30~200 ml,平均115 ml,术中均未输血.术后住院时间4~10 d,平均5.7 d.术后随访2~38个月,仅1例肾上腺皮质癌患者术后1年出现复发,其余患者均未见肿瘤复发. 结论 复发肾上腺肿瘤因原手术区域粘连、解剖异常等具有一定的手术难度,再次手术时选择不同的手术径路,可最大限度避开原手术粘连部位.对于体积较大的复发肾上腺肿瘤,机器人辅助腹腔镜手术不失为一种创伤小、安全可靠、疗效确切的手术方法.